Patients found the appointment system easy to use and reported that they were able to access care when they needed urgent support and treatment. The practice had acted following below average feedback about access to appointments. The telephone system was in the process of being upgraded and additional staff had been recruited to offer a wider range of appointments.

There was a strong focus on continuous learning and improvement at all levels of the organisation.

The practice was proactive in reducing the risk of patients developing long term medical conditions. For example, it identified and acted with patients at risk of developing diabetes.

Patients with long term conditions could access support to deal with the psychological issues surrounding their physical condition. Talking therapy was available at the practice premises.

The practice was active in supporting patients to deal with social issues as well as their physical health by providing clinics for social workers at the practice.

At the time of the inspection the practice was unaware that exception reporting (the removal of patients from monitoring due to either contra indication of treatment or failure to attend for review) in 2017/18 had risen from the previous year.

We saw one area of outstanding practice:

The practice had completed a review of 472 patients who had a record of non-specific allergy. This resulted in 440 patients having a specific allergy entered in their records to support safer prescribing and treatment.

The areas where the provider should make improvements are:

The practice plan for increasing uptake of cervical screening requires monitoring and review to evaluate progress.

The practice provided evidence that training in identifying signs of sepsis had been undertaken. The effectiveness of this training requires review with non-clinical staff.

The practice should improve the system of reporting the removal of patients with long term conditions to more accurately reflect those that have not received the treatment and monitoring included in the national QOF incentive scheme.

Inspection report

Download full report

Inspection areas

Safe

Good

Updated 11 December 2018

We rated the practice as good for providing safe services.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents was available to staff.

Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)

Staff took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect.

The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.

There was an effective system to manage infection prevention and control. Cleaning standards were monitored and our observations found the practice to be clean and tidy.

The practice had arrangements to ensure that facilities and equipment were safe and in good working order.

Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety.

Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.

There was an effective induction system for temporary staff tailored to their role.

The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.

Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.

When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

The care records we saw showed that information needed to deliver safe care and treatment was available to staff.

The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.

Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

The practice had reliable systems for appropriate and safe handling of medicines.

Data showed the practice was in line with national averages for managing hypnotics and antimicrobial medicines.

Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and took action to support good antimicrobial stewardship in line with local and national guidance.

There were protocols requiring date of birth to be checked for verifying the identity of patients during remote or online consultations.

Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.

Track record on safety

The practice had a good track record on safety.

There were comprehensive risk assessments in relation to safety issues.

The practice monitored and reviewed safety using information from a range of sources.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so. The practice had developed their own database where all staff could post any learning about safety issues. Staff knew where to access this database and how to post entries to it.

There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and acted to improve safety in the practice.

The practice acted on and learned from external safety events as well as patient and medicine safety alerts. A lead GP took responsibility for ensuring action required from medicines alerts was completed. Nursing staff oversaw action required if there was a safety alert relating to medical equipment in use at the practice.

Inspection report

Download full report

Effective

We rated the practice and most of the population groups as good for providing effective services overall with the exception of people with a long term condition

which we rated requires improvement

.

The system operated by the practice to recall patients was not operated effectively. This resulted in fewer patients in this group attending for their tests and appointments than the local and national averages.

Effective needs assessment, care and treatment

The practice hadsystems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.

We saw no evidence of discrimination when making care and treatment decisions.

There was a practice patient information room. This included a facility where patients could take their own blood pressure. The blood pressure monitor linked directly into the patient’s medical notes and there was system to alert clinicians to review the results of these blood pressure tests.

Staff advised patients what to do if their condition got worse and where to seek further help and support.

The practice identified patients at risk of developing diabetes and worked with this group to reduce the risk. This work had been successful and had been adopted by other practices within the local clinical commissioning group (CCG).

Following a significant event relating to potential incorrect prescribing one of the GPs carried out a project to review 472 patients that had an entry of a non-specific allergy within their records. This resulted in 440 of these patients having a more accurate record of their specific allergy thus reducing the risk of clinicians giving advice contra to the specific allergy. It also reduced the risk of prescribing a medicine which may not be suited to the patient’s allergy.

Older people:

Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.

The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs. There was a designated member of staff that ensured follow up of patients discharged from hospital was completed within three days. In addition, there was a further follow up timetabled for these patients six weeks later.

Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.

Staff who were responsible for reviews of patients with long term conditions had received specific training.

GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.

Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.

The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension)

The practice’s performance on quality indicators for long term conditions was above average compared to both national and local averages. However, the practice exception rates (exception rates arise from patients who have been invited to attend for review and do not attend or it may not be appropriate to carry out the review). Our detailed review of the practice process to invite patient for their reviews showed that patients received up to six invitations to attend for their monitoring appointments. The decision to except (remove) a patient from the monitoring measures was always made by a clinician.

The practice held joint clinics with the local diabetes specialist to support patients who encountered problems managing their diabetic condition. Clinicians at the practice had a strong focus on working with patients whose diabetes was not well controlled. This had resulted in a 4% reduction in high levels of HbA1c (HbA1c is a measurement of glucose in the blood. Reducing HbA1c levels lowers the risk of complications arising from diabetes).

The practice hosted a member of the talking therapies team who worked with patients who had long term medical conditions. This work focused on assisting patients in coming to terms and coping with the psychological issues arising from a diagnosis of a long-term condition.

The exception rate for carrying out annual asthma reviews had been four times higher than the local average in data for 2017/18. The practice had an additional safety check in place for patients diagnosed with asthma. When a patient requested nine inhalers in any one year they were required to make contact with the practice before they received any further prescription for inhalers. The practice took this measure because high usage of inhalers often indicated that the asthma condition was not being well controlled. Data from 2018/19 shows the exception rate for asthma reviews has fallen from 28% to 10%.

The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.

Working age people (including those recently retired and students):

The practice’s uptake for cervical screening was 73%, which was in line with local and national averages but below the 80% coverage target for the national screening programme.

The practice’s uptake for breast and bowel cancer screening was above the national average.

Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.

The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

People experiencing poor mental health (including people with dementia):

The practice assessed and monitored the physical health of people with mental illness, severe mental illness and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication.

When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.

Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.

The practice offered annual health checks to patients with a learning disability. The practice showed us the comprehensive checklist used to complete the health checks for this group of patients. We noted that when the new checklist was first adopted that completion of the health review had not been correctly coded in the patient’s record. The practice was in the process of correcting this anomaly.

The practices performance on quality indicators for mental health was above local and national averages. Whilst exception rates were high the practice held data that showed the exception rate had also been affected by incorrect coding of physical health checks for this group of patients and that clinicians had made appropriate decisions when patients were removed from monitoring of their mental health conditions.

GPs at the practice carried out care and treatment of a group of patients with long term mental health problems living in a local care establishment.

Monitoring care and treatment

The practice hada comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided by carrying out audits. Where appropriate, clinicians took part in local and national improvement initiatives.

The practice performance was above average against national quality indicators included within the QOF national scheme. At the time of the inspection the practice was unaware that exception reporting (the removal of patients from monitoring due to either contra indication of treatment or failure to attend for review) in 2017/18 had risen from the previous year. This had resulted in the number of exceptions being significantly higher than both local and national averages. For example, the exception rate from the annual asthma review measure was 31% compared to the clinical commissioning group (CCG) average of 5% and England average of 8%. Within two days of inspection the practice had undertaken an audit and produced data from their clinical database that showed the actual exception rates to be much lower than reported due to patients attending for their treatment, test or review after the exception code had been added to their record. This occurred because the practice offered additional reminders (up to six compared to the required three) after the exception had been approved by a GP.

The practice used information about care and treatment to make improvements.

The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.

The practice had undertaken a review of staffing to expand the clinical team. This had resulted in recruitment of clinical pharmacists and a physiotherapist.

Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.

The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. Staff gave us examples of training courses they had attended. Practice nursing staff were encouraged to expand their skills. For example, one member of the nursing team had received additional training to enable them to review the care of patients with respiratory problems.

The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.

There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.

The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.

Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.

The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.

Staff encouraged and supported patients to be involved in monitoring and managing their own health. For example, by recording their own blood pressure.

Staff discussed changes to care or treatment with patients and their carers as necessary.

The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

Most clinicians understood the requirements of legislation and guidance when considering consent and decision making. However, one member of the nursing team was not clear on the legislation regarding consent for patients under the age of 16. The practice took immediate steps to address this when we discussed our findings with them.

Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

The practice monitored the process for seeking consent appropriately. Staff were aware of the need to request consent to share records with referrals in line with GDPR principles (General Data Protection Regulation).

The practices GP patient survey results were above local and national averages for questions relating to kindness, respect and compassion.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.

The practice proactively identified carers and supported them.

The practices GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

Privacy and dignity

The practice respected patients’ privacy and dignity.

When patients wanted to discuss sensitive issues, or appeared distressed reception staff offered them a private room to discuss their needs.

Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Inspection report

Download full report

Responsive

We rated the practice, and all of the population groups, as good for providing responsive services

.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

The practice understood the needs of its population and tailored services in response to those needs.

Telephone and web GP consultations were available which supported patients who were unable to attend the practice during normal working hours. The practice offered online consultations.

The facilities and premises were appropriate for the services delivered. For example, a specialist couch had been installed in the minor operations treatment room to improve safety for patients whose weight may be too great for a standard examination couch.

The practice made reasonable adjustments when patients found it hard to access services. For example, the patient record system clearly identified patients with either hearing or visual impairment. This enabled the GPs and nurses to go to the waiting room to collect these patients for their appointments in case the patient missed the appointment call message.

The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.

Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.

The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GPs also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability. In addition, the practice funded a bus service three days a week to bring patients to and from the practice for their appointments.

People with long-term conditions:

Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met.

When appropriate multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs. This included offering long term condition review appointments during Saturday morning extended hours clinics to assist patients in this group that worked on weekdays.

The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.

All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, extended opening hours and Saturday appointments.

People who worked and found it difficult to attend the practice could access online consultations via the practice website.

The practice worked with the clinical commissioning group (CCG) to offer access to appointments on weekday evenings and at weekends via the local out of hours provider.

Patients could order their repeat prescriptions online and have these sent to the pharmacy of their choice.

People whose circumstances make them vulnerable:

The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.

People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

Staff were trained to support carers and identify any extra support this group of patients required.

People experiencing poor mental health (including people with dementia):

Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.

One of the GPs undertook a weekly visit to a mental health rehabilitation unit to provide physical care to residents living at the unit.

There was a visiting talking therapies service which supported patients with mental health problems.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs.

Waiting times, delays and cancellations were minimal and managed appropriately.

Patients with the most urgent needs had their care and treatment prioritised. The appointment system in operation enabled all patients with an urgent need for an appointment to be seen on the day they requested an appointment. There was no limit on the number of urgent on the day appointments offered.

Patients reported that the appointment system was easy to use.

The practices GP patient survey results were below local and national averages for questions relating to access to care and treatment. However, the practice was aware of the feedback from the national survey. Since the survey period a second clinical pharmacist and an additional part time GP had been appointed to provide a wider range of appointments.

The practice was in the process of installing an upgraded more responsive telephone system. This was being installed on the day of inspection.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.

The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care. Staff who gave us written feedback were able to identify learning from complaints.

Well-led

Leaders had the capacity and skills to deliver high-quality, sustainable care.

Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.

Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice. For example, lead roles were shared between senior GPs and the younger GPs at the practice.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities.

Staff were aware of and understood the vision, values and strategy and their role in achieving them.

The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.

The practice monitored progress against delivery of the strategy.

The practice had a plan to care for people that would move into a 92 bed care home under construction on the same site as the practice premises.

GPs had attended preliminary planning forums about a plan to build over 100 new houses within a half a mile of the practice premises.

Culture

The practice had a culture of high-quality sustainable care.

Staff stated they felt respected, supported and valued. They were proud to work in the practice.

The practice focused on the needs of patients.

Leaders and managers acted on behaviour and performance inconsistent with the vision and values.

Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The providerwasaware of and had systems to ensure compliance with the requirements of the duty of candour.

Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.

There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff, who had been in post for over 12 months, received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. New staff received relevant induction and a review of their performance within six months of commencing work at the practice.

There was a strong emphasis on the safety and well-being of all staff. This included a local project to identify and manage stress within the practice team.

The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.

There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management but these were not always operated effectively.

Structures, processes and systems to support good governance and management were clearly set out, understood and in the majority of areas of activity were effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.

Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control

Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

At the time of the inspection the practice was unaware that exception reporting (the removal of patients from monitoring due to either contra indication of treatment or failure to attend for review) in 2017/18 had risen from the previous year. This had resulted in the number of exceptions being significantly above local and national averages. Within two days of inspection the practice had undertaken an audit and produced data from their clinical database that showed the actual exception rates to be much lower than reported. This was due to patients attending for their treatment, test or review after the exception code had been added to their record. This occurred because the practice offered additional reminders (up to six compared to the required three) after the exception had been approved by a GP.

Managing risks, issues and performance

There wereclear and effectiveprocesses for managing risks, issues and performance.

There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.

The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.

Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality. For example, by identifying and working with patients at risk of developing diabetes.

The practice had plans in place and had trained staff for major incidents.

The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice mostly actedon appropriate and accurate information.

Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.

Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.

The practice used performance information which was reported and monitored and management and staff were held to account.

The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses. The practice was responsive when weaknesses were identified. For example, we discussed the accuracy of the register of patients diagnosed with asthma and the failure of patients in this group to respond to invitations to monitor their care. This resulted in the practice commencing a review of their asthma register and processes to follow up non-attenders.

The practice used information technology systems to monitor and improve the quality of care. The practice was a test site for new care plan templates for patients with diabetes and the elderly frail.

The practice submitted data or notifications to external organisations as required.

There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support high-quality sustainable services.

A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.

The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

Therewas evidence of systems and processes for learning, continuous improvement and innovation.

There was a focus on continuous learning and improvement.

Staff knew about improvement methods and had the skills to use them.

The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.

Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance. There was a team meeting structure in place and staff felt encouraged to attend team meetings to share their views, ideas and concerns.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.